This application relates generally to healthcare transactions. More specifically, this application relates to healthcare eligibility transactions.
The financial structure of the healthcare system in the United States provides a good example of a more general class of systems that rely on eligibility information when providing services. The healthcare model is structured around three principal parties: a patient, a healthcare provider, and an insurer. In a typical arrangement, services provided by the healthcare provider to the patient are paid for by the insurer. This may be subject to a variety of conditions depending on the specific type of the service and may be subject to a requirement that the patient make a contribution towards the cost. For instance, certain high-cost procedures frequently require some form of preapproval by the insurer before the service is provided; this gives the insurer an opportunity to confirm the medical necessity of the procedure before it is performed and the cost incurred. The contribution towards the cost made by the patient is frequently referred to in the art as a “copay,” which is a truncation of the complete term “copayment.”
The eligibility of a patient for certain services may depend on the particular insurance coverage provided by the insurer, with coverage details varying among insurance plans, among different patient employers, and sometimes even among different patients. If a particular patient is not eligible for certain service, alternative arrangements must be made because the healthcare provided cannot expect to receive subsequent payment for the service from the insurer. When a patient visits a healthcare provider, there thus needs to be some mechanism to verify the eligibility of the patent for certain services pursuant to an insurance agreement. Eligibility has traditionally been verified by obtaining insurance information from the patient, with staff of the healthcare provider confirming the information with the insurer and checking eligibility for services by telephone. Such a process is generally time-consuming for the staff, resulting in inefficiencies in the operation of a healthcare practice.
There is accordingly a need in the art for improved methods and systems of verifying eligibility for services.